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Breech Presentation and Maternal and Perinatal Outcome in a Tertiary Care Teaching Hospital of Central Nepal

• Manisha Acharya College of Medical Sciences
• Praveen Kumar
• Rubina Shrestha
• Puja Baniya Chhetri
• Mamata Lamichhane
• Srijana Neupane https://orcid.org/0009-0000-2457-4920

Introduction: Breech is the commonest malpresentation. The objective of this study is to find out the prevalence of breech presentation at term. It also aims to present the mode of delivery conducted and to highlight the maternal and fetal complications associated with it. Methods:   This   was   a   descriptive   cross-sectional   study   conducted in Department of Obstetrics and Gynaecology department of College of Medical Sciences done over a period of 2 years. All term pregnant women (≥ 37 weeks) aged 16 years and above, admitted to the maternity and labor ward with the diagnosis of singleton breech presentation during the study period were included in the study. Results: The incidence of breech presentation at term was 5.03%. Out of these, only 7 (18.92%) patients underwent breech vaginal delivery. Mean maternal age was 28.07 (± 11.56) years and  majority were primigravidae. The mean birth weight of newborn was 2.8±0.5 kg. Conclusions: Breech presentation can result in both maternal and fetal complications. Skills related to conducting delivery in  breech presentation must be learned by all those who manage pregnant women.

Author Biography

Srijana neupane.

Madhyabindu Municipality Hospital, Nawalpur, Nepal

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Current Issue

Journal of College of Medical Sciences-Nepal ISSN 2091-0657 eISSN 2091-0673

Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for vertex presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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What Causes Breech Presentation?

Learn more about the types, causes, and risks of breech presentation, along with how breech babies are typically delivered.

What Is Breech Presentation?

Types of breech presentation, what causes a breech baby, can you turn a breech baby, how are breech babies delivered.

FatCamera/Getty Images

Toward the end of pregnancy, your baby will start to get into position for delivery, with their head pointed down toward the vagina. This is otherwise known as vertex presentation. However, some babies turn inside the womb so that their feet or buttocks are poised to be delivered first, which is commonly referred to as breech presentation, or a breech baby.

As you near the end of your pregnancy journey, an OB-GYN or health care provider will check your baby's positioning. You might find yourself wondering: What causes breech presentation? Are there risks involved? And how are breech babies delivered? We turned to experts and research to answer some of the most common questions surrounding breech presentation, along with what causes this positioning in the first place.

During your pregnancy, your baby constantly moves around the uterus. Indeed, most babies do somersaults up until the 36th week of pregnancy , when they pick their final position in the womb, says Laura Riley , MD, an OB-GYN in New York City. Approximately 3-4% of babies end up “upside-down” in breech presentation, with their feet or buttocks near the cervix.

Breech presentation is typically diagnosed during a visit to an OB-GYN, midwife, or health care provider. Your physician can feel the position of your baby's head through your abdominal wall—or they can conduct a vaginal exam if your cervix is open. A suspected breech presentation should ultimately be confirmed via an ultrasound, after which you and your provider would have a discussion about delivery options, potential issues, and risks.

There are three types of breech babies: frank, footling, and complete. Learn about the differences between these breech presentations.

Frank Breech

With frank breech presentation, your baby’s bottom faces the cervix and their legs are straight up. This is the most common type of breech presentation.

Footling Breech

Like its name suggests, a footling breech is when one (single footling) or both (double footling) of the baby's feet are in the birth canal, where they’re positioned to be delivered first .

Complete Breech

In a complete breech presentation, baby’s bottom faces the cervix. Their legs are bent at the knees, and their feet are near their bottom. A complete breech is the least common type of breech presentation.

Other Types of Mal Presentations

The baby can also be in a transverse position, meaning that they're sideways in the uterus. Another type is called oblique presentation, which means they're pointing toward one of the pregnant person’s hips.

Typically, your baby's positioning is determined by the fetus itself and the shape of your uterus. Because you can't can’t control either of these factors, breech presentation typically isn’t considered preventable. And while the cause often isn't known, there are certain risk factors that may increase your risk of a breech baby, including the following:

• The fetus may have abnormalities involving the muscular or central nervous system
• The uterus may have abnormal growths or fibroids
• There might be insufficient amniotic fluid in the uterus (too much or too little)
• This isn’t your first pregnancy
• You have a history of premature delivery
• You have placenta previa (the placenta partially or fully covers the cervix)
• You’re pregnant with multiples
• You’ve had a previous breech baby

In some cases, your health care provider may attempt to help turn a baby in breech presentation through a procedure known as external cephalic version (ECV). This is when a health care professional applies gentle pressure on your lower abdomen to try and coax your baby into a head-down position. During the entire procedure, the fetus's health will be monitored, and an ECV is often performed near a delivery room, in the event of any potential issues or complications.

However, it's important to note that ECVs aren't for everyone. If you're carrying multiples, there's health concerns about you or the baby, or you've experienced certain complications with your placenta or based on placental location, a health care provider will not attempt an ECV.

The majority of breech babies are born through C-sections . These are usually scheduled between 38 and 39 weeks of pregnancy, before labor can begin naturally. However, with a health care provider experienced in delivering breech babies vaginally, a natural delivery might be a safe option for some people. In fact, a 2017 study showed similar complication and success rates with vaginal and C-section deliveries of breech babies.

That said, there are certain known risks and complications that can arise with an attempt to deliver a breech baby vaginally, many of which relate to problems with the umbilical cord. If you and your medical team decide on a vaginal delivery, your baby will be monitored closely for any potential signs of distress.

Ultimately, it's important to know that most breech babies are born healthy. Your provider will consider your specific medical condition and the position of your baby to determine which type of delivery will be the safest option for a healthy and successful birth.

ACOG. If Your Baby Is Breech .

American Pregnancy Association. Breech Presentation .

Gray CJ, Shanahan MM. Breech Presentation . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

Mount Sinai. Breech Babies .

Takeda J, Ishikawa G, Takeda S. Clinical Tips of Cesarean Section in Case of Breech, Transverse Presentation, and Incarcerated Uterus . Surg J (N Y). 2020 Mar 18;6(Suppl 2):S81-S91. doi: 10.1055/s-0040-1702985. PMID: 32760790; PMCID: PMC7396468.

Shanahan MM, Gray CJ. External Cephalic Version . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. 

Fonseca A, Silva R, Rato I, Neves AR, Peixoto C, Ferraz Z, Ramalho I, Carocha A, Félix N, Valdoleiros S, Galvão A, Gonçalves D, Curado J, Palma MJ, Antunes IL, Clode N, Graça LM. Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes? Acta Med Port. 2017 Jun 30;30(6):479-484. doi: 10.20344/amp.7920. Epub 2017 Jun 30. PMID: 28898615.

Related Articles

When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Breech presentation

• Overview  
• Theory  
• Diagnosis  
• Management  
• Follow up  
• Resources  

Breech presentation refers to the baby presenting for delivery with the buttocks or feet first rather than head.

Associated with increased morbidity and mortality for the mother in terms of emergency caesarean section and placenta praevia; and for the baby in terms of preterm birth, small fetal size, congenital anomalies, and perinatal mortality.

Incidence decreases as pregnancy progresses and by term occurs in 3% to 4% of singleton term pregnancies.

Treatment options include external cephalic version to increase the likelihood of vaginal birth or a planned caesarean section, the optimal gestation being 37 and 39 weeks, respectively.

Planned caesarean section is considered the safest form of delivery for infants with a persisting breech presentation at term.

Breech presentation in pregnancy occurs when a baby presents with the buttocks or feet rather than the head first (cephalic presentation) and is associated with increased morbidity and mortality for both the mother and the baby. [1] Cunningham F, Gant N, Leveno K, et al. Williams obstetrics. 21st ed. New York: McGraw-Hill; 1997. [2] Kish K, Collea JV. Malpresentation and cord prolapse. In: DeCherney AH, Nathan L, eds. Current obstetric and gynecologic diagnosis and treatment. New York: McGraw-Hill Professional; 2002. There is good current evidence regarding effective management of breech presentation in late pregnancy using external cephalic version and/or planned caesarean section.

History and exam

Key diagnostic factors.

• presence of risk factors
• buttocks or feet as the presenting part
• fetal head under costal margin
• fetal heartbeat above the maternal umbilicus

Other diagnostic factors

• subcostal tenderness
• pelvic or bladder pain

Risk factors

• premature fetus
• small for gestational age fetus
• nulliparity
• fetal congenital anomalies
• previous breech delivery
• uterine abnormalities
• abnormal amniotic fluid volume
• placental abnormalities
• female fetus

Diagnostic investigations

1st investigations to order.

• transabdominal/transvaginal ultrasound

Treatment algorithm

<37 weeks' gestation and in labour, ≥37 weeks' gestation not in labour, ≥37 weeks' gestation in labour: no imminent delivery, ≥37 weeks' gestation in labour: imminent delivery, contributors, natasha nassar, phd.

Associate Professor

Menzies Centre for Health Policy

Sydney School of Public Health

University of Sydney

Disclosures

NN has received salary support from Australian National Health and a Medical Research Council Career Development Fellowship; she is an author of a number of references cited in this topic.

Christine L. Roberts, MBBS, FAFPHM, DrPH

Research Director

Clinical and Population Health Division

Perinatal Medicine Group

Kolling Institute of Medical Research

CLR declares that she has no competing interests.

Jonathan Morris, MBChB, FRANZCOG, PhD

Professor of Obstetrics and Gynaecology and Head of Department

JM declares that he has no competing interests.

Peer reviewers

John w. bachman, md.

Consultant in Family Medicine

Department of Family Medicine

Mayo Clinic

JWB declares that he has no competing interests.

Rhona Hughes, MBChB

Lead Obstetrician

Lothian Simpson Centre for Reproductive Health

The Royal Infirmary

RH declares that she has no competing interests.

Brian Peat, MD

Director of Obstetrics

Women's and Children's Hospital

North Adelaide

South Australia

BP declares that he has no competing interests.

Lelia Duley, MBChB

Professor of Obstetric Epidemiology

University of Leeds

Bradford Institute of Health Research

Temple Bank House

Bradford Royal Infirmary

LD declares that she has no competing interests.

Justus Hofmeyr, MD

Head of the Department of Obstetrics and Gynaecology

East London Private Hospital

East London

South Africa

JH is an author of a number of references cited in this topic.

Differentials

• Transverse lie
• Caesarean birth
• Mode of term singleton breech delivery

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Read common questions on the coronavirus and ACOG’s evidence-based answers.

If Your Baby Is Breech

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Frequently Asked Questions Expand All

In the last weeks of pregnancy, a fetus usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation . A breech presentation occurs when the fetus’s buttocks, feet, or both are in place to come out first during birth. This happens in 3–4% of full-term births.

It is not always known why a fetus is breech. Some factors that may contribute to a fetus being in a breech presentation include the following:

You have been pregnant before.

There is more than one fetus in the uterus (twins or more).

There is too much or too little amniotic fluid .

The uterus is not normal in shape or has abnormal growths such as fibroids .

The placenta covers all or part of the opening of the uterus ( placenta previa )

The fetus is preterm .

Occasionally fetuses with certain birth defects will not turn into the head-down position before birth. However, most fetuses in a breech presentation are otherwise normal.

Your health care professional may be able to tell which way your fetus is facing by placing his or her hands at certain points on your abdomen. By feeling where the fetus's head, back, and buttocks are, it may be possible to find out what part of the fetus is presenting first. An ultrasound exam or pelvic exam may be used to confirm it.

External cephalic version (ECV) is an attempt to turn the fetus so that he or she is head down. ECV can improve your chance of having a vaginal birth. If the fetus is breech and your pregnancy is greater than 36 weeks your health care professional may suggest ECV.

ECV will not be tried if:

You are carrying more than one fetus

There are concerns about the health of the fetus

You have certain abnormalities of the reproductive system

The placenta is in the wrong place

The placenta has come away from the wall of the uterus ( placental abruption )

ECV can be considered if you have had a previous cesarean delivery .

The health care professional performs ECV by placing his or her hands on your abdomen. Firm pressure is applied to the abdomen so that the fetus rolls into a head-down position. Two people may be needed to perform ECV. Ultrasound also may be used to help guide the turning.

The fetus's heart rate is checked with fetal monitoring before and after ECV. If any problems arise with you or the fetus, ECV will be stopped right away. ECV usually is done near a delivery room. If a problem occurs, a cesarean delivery can be performed quickly, if necessary.

Complications may include the following:

Prelabor rupture of membranes

Changes in the fetus's heart rate

Placental abruption

Preterm labor

More than one half of attempts at ECV succeed. However, some fetuses who are successfully turned with ECV move back into a breech presentation. If this happens, ECV may be tried again. ECV tends to be harder to do as the time for birth gets closer. As the fetus grows bigger, there is less room for him or her to move.

Most fetuses that are breech are born by planned cesarean delivery. A planned vaginal birth of a single breech fetus may be considered in some situations. Both vaginal birth and cesarean birth carry certain risks when a fetus is breech. However, the risk of complications is higher with a planned vaginal delivery than with a planned cesarean delivery.

In a breech presentation, the body comes out first, leaving the baby’s head to be delivered last. The baby’s body may not stretch the cervix enough to allow room for the baby’s head to come out easily. There is a risk that the baby’s head or shoulders may become wedged against the bones of the mother’s pelvis. Another problem that can happen during a vaginal breech birth is a prolapsed umbilical cord . It can slip into the vagina before the baby is delivered. If there is pressure put on the cord or it becomes pinched, it can decrease the flow of blood and oxygen through the cord to the baby.

Although a planned cesarean birth is the most common way that breech fetuses are born, there may be reasons to try to avoid a cesarean birth.

A cesarean delivery is major surgery. Complications may include infection, bleeding, or injury to internal organs.

The type of anesthesia used sometimes causes problems.

Having a cesarean delivery also can lead to serious problems in future pregnancies, such as rupture of the uterus and complications with the placenta.

With each cesarean delivery, these risks increase.

If you are thinking about having a vaginal birth and your fetus is breech, your health care professional will review the risks and benefits of vaginal birth and cesarean birth in detail. You usually need to meet certain guidelines specific to your hospital. The experience of your health care professional in delivering breech babies vaginally also is an important factor.

Amniotic Fluid : Fluid in the sac that holds the fetus.

Anesthesia : Relief of pain by loss of sensation.

Breech Presentation : A position in which the feet or buttocks of the fetus would appear first during birth.

Cervix : The lower, narrow end of the uterus at the top of the vagina.

Cesarean Delivery : Delivery of a fetus from the uterus through an incision made in the woman’s abdomen.

External Cephalic Version (ECV) : A technique, performed late in pregnancy, in which the doctor attempts to manually move a breech baby into the head-down position.

Fetus : The stage of human development beyond 8 completed weeks after fertilization.

Fibroids : Growths that form in the muscle of the uterus. Fibroids usually are noncancerous.

Oxygen : An element that we breathe in to sustain life.

Pelvic Exam : A physical examination of a woman’s pelvic organs.

Placenta : Tissue that provides nourishment to and takes waste away from the fetus.

Placenta Previa : A condition in which the placenta covers the opening of the uterus.

Placental Abruption : A condition in which the placenta has begun to separate from the uterus before the fetus is born.

Prelabor Rupture of Membranes : Rupture of the amniotic membranes that happens before labor begins. Also called premature rupture of membranes (PROM).

Preterm : Less than 37 weeks of pregnancy.

Ultrasound Exam : A test in which sound waves are used to examine inner parts of the body. During pregnancy, ultrasound can be used to check the fetus.

Umbilical Cord : A cord-like structure containing blood vessels. It connects the fetus to the placenta.

Uterus : A muscular organ in the female pelvis. During pregnancy, this organ holds and nourishes the fetus.

Vagina : A tube-like structure surrounded by muscles. The vagina leads from the uterus to the outside of the body.

Vertex Presentation : A presentation of the fetus where the head is positioned down.

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What Is Breech?

When a fetus is delivered buttocks or feet first

• Types of Presentation

Risk Factors

Complications.

Breech concerns the position of the fetus before labor . Typically, the fetus comes out headfirst, but in a breech delivery, the buttocks or feet come out first. This type of delivery is risky for both the pregnant person and the fetus.

This article discusses the different types of breech presentations, risk factors that might make a breech presentation more likely, treatment options, and complications associated with a breech delivery.

Verywell / Jessica Olah

Types of Breech Presentation

During the last few weeks of pregnancy, a fetus usually rotates so that the head is positioned downward to come out of the vagina first. This is called the vertex position.

In a breech presentation, the fetus does not turn to lie in the correct position. Instead, the fetus’s buttocks or feet are positioned to come out of the vagina first.

At 28 weeks of gestation, approximately 20% of fetuses are in a breech position. However, the majority of these rotate to the proper vertex position. At full term, around 3%–4% of births are breech.

The different types of breech presentations include:

• Complete : The fetus’s knees are bent, and the buttocks are presenting first.
• Frank : The fetus’s legs are stretched upward toward the head, and the buttocks are presenting first.
• Footling : The fetus’s foot is showing first.

Signs of Breech

There are no specific symptoms associated with a breech presentation.

Diagnosing breech before the last few weeks of pregnancy is not helpful, since the fetus is likely to turn to the proper vertex position before 35 weeks gestation.

A healthcare provider may be able to tell which direction the fetus is facing by touching a pregnant person’s abdomen. However, an ultrasound examination is the best way to determine how the fetus is lying in the uterus.

Most breech presentations are not related to any specific risk factor. However, certain circumstances can increase the risk for breech presentation.

These can include:

• Previous pregnancies
• Multiple fetuses in the uterus
• An abnormally shaped uterus
• Uterine fibroids , which are noncancerous growths of the uterus that usually appear during the childbearing years
• Placenta previa, a condition in which the placenta covers the opening to the uterus
• Preterm labor or prematurity of the fetus
• Too much or too little amniotic fluid (the liquid that surrounds the fetus during pregnancy)
• Fetal congenital abnormalities

Most fetuses that are breech are born by cesarean delivery (cesarean section or C-section), a surgical procedure in which the baby is born through an incision in the pregnant person’s abdomen.

In rare instances, a healthcare provider may plan a vaginal birth of a breech fetus. However, there are more risks associated with this type of delivery than there are with cesarean delivery. 

Before cesarean delivery, a healthcare provider might utilize the external cephalic version (ECV) procedure to turn the fetus so that the head is down and in the vertex position. This procedure involves pushing on the pregnant person’s belly to turn the fetus while viewing the maneuvers on an ultrasound. This can be an uncomfortable procedure, and it is usually done around 37 weeks gestation.

ECV reduces the risks associated with having a cesarean delivery. It is successful approximately 40%–60% of the time. The procedure cannot be done once a pregnant person is in active labor.

Complications related to ECV are low and include the placenta tearing away from the uterine lining, changes in the fetus’s heart rate, and preterm labor.

ECV is usually not recommended if the:

• Pregnant person is carrying more than one fetus
• Placenta is in the wrong place
• Healthcare provider has concerns about the health of the fetus
• Pregnant person has specific abnormalities of the reproductive system

Recommendations for Previous C-Sections

The American College of Obstetricians and Gynecologists (ACOG) says that ECV can be considered if a person has had a previous cesarean delivery.

During a breech delivery, the umbilical cord might come out first and be pinched by the exiting fetus. This is called cord prolapse and puts the fetus at risk for decreased oxygen and blood flow. There’s also a risk that the fetus’s head or shoulders will get stuck inside the mother’s pelvis, leading to suffocation.

Complications associated with cesarean delivery include infection, bleeding, injury to other internal organs, and problems with future pregnancies.

A healthcare provider needs to weigh the risks and benefits of ECV, delivering a breech fetus vaginally, and cesarean delivery.

In a breech delivery, the fetus comes out buttocks or feet first rather than headfirst (vertex), the preferred and usual method. This type of delivery can be more dangerous than a vertex delivery and lead to complications. If your baby is in breech, your healthcare provider will likely recommend a C-section.

A Word From Verywell

Knowing that your baby is in the wrong position and that you may be facing a breech delivery can be extremely stressful. However, most fetuses turn to have their head down before a person goes into labor. It is not a cause for concern if your fetus is breech before 36 weeks. It is common for the fetus to move around in many different positions before that time.

At the end of your pregnancy, if your fetus is in a breech position, your healthcare provider can perform maneuvers to turn the fetus around. If these maneuvers are unsuccessful or not appropriate for your situation, cesarean delivery is most often recommended. Discussing all of these options in advance can help you feel prepared should you be faced with a breech delivery.

American College of Obstetricians and Gynecologists. If your baby is breech .

TeachMeObGyn. Breech presentation .

MedlinePlus. Breech birth .

Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term . Cochrane Database Syst Rev . 2015 Apr 1;2015(4):CD000083. doi:10.1002/14651858.CD000083.pub3

By Christine Zink, MD Dr. Zink is a board-certified emergency medicine physician with expertise in the wilderness and global medicine.

Breech Presentation

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• Breech presentation : fetal head at uterine fundus, buttocks or feet over maternal pelvis; occurs in 3-4% of all fetuses in the UK.
• Aetiology : mostly idiopathic.
• Complete (flexed) breech : one or both knees flexed.
• Footling (incomplete) breech : one or both feet below fetal buttocks, hips and knees extended.
• Frank (extended) breech : hips flexed, knees extended; increased risk of developmental dysplasia of the hip.
• Maternal : multiparity, fibroids, previous breech, Mullerian duct abnormalities.
• Fetal : preterm, macrosomia, fetal abnormalities, multiple pregnancy.
• Placental : placenta praevia, polyhydramnios, oligohydramnios, amniotic bands.
• Breech common before 36 weeks, often asymptomatic, diagnosed incidentally.
• 20% breech at 28 weeks, 16% at 32 weeks, 3-4% at term.
• Longitudinal lie, head at fundus, irregular mass over pelvis, fetal heart auscultated higher, palpation of feet/sacrum at cervical os during vaginal examination.
• Investigations : ultrasound scan to confirm breech presentation and assess for abnormalities.
• External cephalic version (ECV) : manual rotation under ultrasound; success rate 40% in primiparous, 60% in multiparous; contraindications include antepartum haemorrhage, ruptured membranes, previous caesarean, major uterine abnormality, multiple pregnancy, abnormal CTG.
• Vaginal delivery : risks include head entrapment, birth asphyxia, intracranial haemorrhage, perinatal mortality, cord prolapse, trauma; contraindications include footling breech, macrosomia, growth restriction, other complications of vaginal birth, lack of trained staff, previous caesarean.
• Caesarean section : elective procedure at term, preferred for preterm babies, unsuccessful ECV, or maternal preference; fewer risks than vaginal delivery.
• Fetal complications : developmental dysplasia of the hip, cord prolapse, fetal head entrapment, birth asphyxia, intracranial haemorrhage, perinatal mortality.
• ECV complications : transient fetal heart abnormalities, fetomaternal haemorrhage, placental abruption (rare).

Introduction

Breech presentation is a type of malpresentation and occurs when the fetal head lies over the uterine fundus and fetal buttocks or feet present over the maternal pelvis (instead of cephalic/head presentation).

The incidence in the United Kingdom of breech presentation is 3-4% of all fetuses. 1

Breech presentation is most commonly idiopathic .

Types of breech presentation

The three types of breech presentation are:

• Complete (flexed) breech : one or both knees are flexed (Figure 1)
• Footling (incomplete) breech : one or both feet present below the fetal buttocks, with hips and knees extended (Figure 2)
• Frank (extended) breech : both hips flexed and both knees extended. Babies born in frank breech are more likely to have developmental dysplasia of the hip (Figure 3)

Risk factors

Risk factors for breech presentation can be divided into maternal , fetal and placental risk factors:

• Maternal : multiparity, fibroids, previous breech presentation, Mullerian duct abnormalities
• Fetal : preterm, macrosomia, fetal abnormalities (anencephaly, hydrocephalus, cystic hygroma), multiple pregnancy
• Placental : placenta praevia , polyhydramnios, oligohydramnios , amniotic bands

Clinical features

Before 36 weeks , breech presentation is not significant, as the fetus is likely to revert to a cephalic presentation. The mother will often be asymptomatic with the diagnosis being incidental.

The incidence of breech presentation is approximately 20% at 28 weeks gestation, 16% at 32 weeks gestation and 3-4% at term . Therefore, breech presentation is more common in preterm labour . Most fetuses with breech presentation in the early third trimester will turn spontaneously and be cephalic at term.

However, spontaneous version rates for nulliparous women with breech presentation at 36 weeks of gestation are less than 10% .

Clinical examination

Typical clinical findings of a breech presentation include:

• Longitudinal lie
• Head palpated at the fundus
• Irregular mass over pelvis (feet, legs and buttocks)
• Fetal heart auscultated higher on the maternal abdomen
• Palpation of feet or sacrum at the cervical os during vaginal examination

For more information, see the Geeky Medics guide to obstetric abdominal examination .

Positions in breech presentation

There are multiple fetal positions in breech presentation which are described according to the relation of the fetal sacrum to the maternal pelvis .

These are: direct sacroanterior, left sacroanterior, right sacroanterior, direct sacroposterior, right sacroposterior, left sacroposterior, left sacrotransverse and right sacrotranverse. 5

Investigations

An ultrasound scan is diagnostic for breech presentation. Growth, amniotic fluid volume and anatomy should be assessed to check for abnormalities.

There are three management options for breech presentation at term, with consideration of maternal choice: external cephalic version , vaginal delivery and Caesarean section .

External cephalic version

External cephalic version (ECV) involves manual rotation of the fetus into a cephalic presentation by applying pressure to the maternal abdomen under ultrasound guidance. Entonox and subcutaneous terbutaline are used to relax the uterus.

ECV has a 40% success rate in primiparous women and 60% in multiparous women . It should be offered to nulliparous women at 36 weeks and multiparous women at 37 weeks gestation. 

If ECV is unsuccessful, then delivery options include elective caesarean section or vaginal delivery. 

Contraindications for undertaking external cephalic version include:

• Antepartum haemorrhage
• Ruptured membranes
• Previous caesarean section
• Major uterine abnormality  
• Multiple pregnancy 
• Abnormal cardiotocography (CTG) 

Vaginal delivery

Vaginal delivery is an option but carries risks including head entrapment, birth asphyxia, intracranial haemorrhage, perinatal mortality, cord prolapse and fetal and/or maternal trauma.

The preference is to deliver the baby without traction and with an anterior sacrum during delivery to decrease the risk of fetal head entrapment .

The mother may be offered an epidural , as vaginal breech delivery can be very painful. 6

Contraindications for vaginal delivery in a breech presentation include:

• Footling breech: the baby’s head and trunk are more likely to be trapped if the feet pass through the dilated cervix too soon
• Macrosomia: usually defined as larger than 3800g
• Growth restricted baby: usually defined as smaller than 2000g
• Other complications of vaginal birth: for example, placenta praevia and fetal compromise
• Lack of clinical staff trained in vaginal breech delivery

Caesarean section

A caesarian section booked as an elective procedure at term is the most common management for breech presentation.

Caesarean section is preferred for preterm babies (due to an increased head to abdominal circumference ratio in preterm babies) and is used if the external cephalic version is unsuccessful or as a maternal preference. This option has fewer risks than a vaginal delivery. 

Complications

Fetal complications of breech presentation include:

• Developmental dysplasia of the hip (DDH)
• Cord prolapse
• Fetal head entrapment
• Birth asphyxia
• Intracranial haemorrhage
• Perinatal mortality

Complications of external cephalic version include:

• Transient fetal heart abnormalities (common)
• Fetomaternal haemorrhage
• Placental abruption (rare)

Miss Saba Al Juboori

Consultant in Obstetrics and Gynaecology

Miss Neeraja Kuruba

Dr chris jefferies.

• Oxford Handbook of Obstetrics and Gynaecology. Breech Presentation: Overview. Published in 2011.
• Jemimah Thomas. Image: Complete breech.
• Bonnie Urquhart Gruenberg. Footling breech. Licence: [ CC BY-SA ]
• Bonnie Urquhart Gruenberg. Frank breech . Licence: [ CC BY-SA ]
• A Comprehensive Textbook of Obstetrics and Gynaecology. Chapter 50: Malpresentation and Malposition: Breech Presentation. Published in 2011.
• Diana Hamilton Fairley. Lecture Notes: Obstetrics and Gynaecology, Malpresentation, Breech Presentation. Published in 2009.

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• v.2020; 2020

Maternal and Perinatal Outcomes of Singleton Term Breech Vaginal Delivery at a Tertiary Care Center in Nepal: A Retrospective Analysis

Tulasa basnet.

1 Department of Obstetrics and Gynecology, B. P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal

Baburam Dixit Thapa

Ramesh shrestha, sarita sitaula.

2 B and B Medical Institute, Lalitpur, Nepal

Associated Data

The hospital does not have a digital record of the data, and it was obtained by reviewing patient case files. The supporting data are available from the corresponding author upon request.

Breech presentation is associated with increased rates of maternal and perinatal morbidity regardless of mode of delivery. After the results of Term Breech Trial, most of the countries adopted the protocol of cesarean section for term breech delivery because of which breech vaginal delivery is becoming rare. The aim of this study is to evaluate short-term maternal and perinatal outcomes of breech vaginal delivery at a tertiary care hospital in Nepal.

A retrospective review of case records of all women who had vaginal breech delivery from April 13, 2016, to April 12, 2018, was conducted, over a period of two years. Available demographic variables, obstetric characteristics, details of labor, postpartum complications, and perinatal complications were recorded and analyzed.

Out of 21,768 cases of deliveries during the study period, the incidence of term breech deliveries was 528 (2.4%) among which the mode of only 84 (17.8%) deliveries was vaginal. Most of the deliveries were unplanned and were conducted because emergency cesarean section could not be performed. Three (3.6%) women had postpartum hemorrhage, and four (4.8%) had entrapment of aftercoming head, two of them requiring Dührssen incisions. Adverse perinatal outcomes were seen in 23.8% of such deliveries with <7 APGAR score at 5 minutes in 20.2%, neonatal admission in 17.7%, and perinatal mortality in 8.3%. The perinatal mortality was significantly associated with birthweight less than 2500 grams as compared to birthweight ≥2500 grams (21.1% versus 4.6%; P =0.043).

The perinatal outcomes for vaginal breech delivery are grave with our existing health facilities, especially when the deliveries are not well planned.

1. Introduction

The incidence of breech presentation at term among singleton pregnancies is 3–5% [ 1 ]. Increased rates of maternal and perinatal morbidity are associated with breech presentation regardless of mode of delivery [ 2 ]. Complications like genital tract injuries are more common with breech presentation in both vaginal and cesarean delivery in the case of mother, while, for fetus, the common risk associated with breech presentation is premature delivery, umbilical cord prolapse, and birth trauma.

There has always been a controversy over the optimal mode of delivery regarding singleton term breech presentation [ 3 ]. Vaginal breech delivery is associated with a 10-fold higher risk of intrapartum fetal death as compared to vaginal cephalic delivery [ 4 ]. Overall, the risk of perinatal mortality for planned vaginal breech delivery is approximately 2/1000. Similarly, the risk is 1/1000 for cephalic vaginal delivery and 0.5/1000 for cesarean section after 39 weeks [ 5 ]. These rates, however, can vary according to healthcare practices and available facilities, socioeconomic condition, and many other factors related to health care delivery systems.

The results of “Term Breech Trial (TBT)” showed that the planned cesarean delivery for singleton term breech presentation is associated with lower perinatal mortality and serious perinatal morbidity in comparison to vaginal delivery [ 6 ]. Owing to this contextual benchmark, the subsequent practices including contemporary ones have sidelined with the findings of the trial resulting in a consistent endorsement of elective cesarean section policy for term breech delivery by most of the health facilities. The follow-up studies of TBT, however, for both maternal and fetal outcomes showed similar results in both cesarean and vaginal delivery groups thereby concluding that planned cesarean delivery does not reduce the risk of death or neurodevelopmental delay in children [ 7 , 8 ]. Furthermore, perinatal or neonatal mortality and severe neonatal morbidity were not reduced even with the policy of elective cesarean section for term breech delivery in settings with high national perinatal mortality rate [ 9 ].

In low-income countries like Nepal, cesarean section for all breech deliveries may not be feasible because of limited surgical infrastructure in most health facilities as well as high cost implication borne by patients themselves and without any third party medical coverage. Regarding this, the American College of Obstetricians and Gynecologists (2016b) as well as Royal College of Obstetricians and Gynecologists (RCOG, 2017) recommend that the risks and benefits of both modes of delivery should be discussed with the patient. They also suggest that an external cephalic version should be offered to women with breech presentation at term if there are no contraindications [ 5 , 10 ]. Moreover, it is explicated that the decision regarding the mode of delivery should be contingent upon the expertise of the healthcare providers and also that planned term breech vaginal delivery may be reasonable under hospital-specific protocol [ 10 ]. This study aimed to find out the short-term maternal and perinatal outcomes of term breech vaginal delivery.

2.1. Study Setting

This study was carried out at B. P. Koirala Institute of Health Sciences (BPKIHS), which is a tertiary care hospital situated in the eastern region of Nepal. The hospital provides obstetrics and gynecologic services to the women of province number one (heretofore unnamed) as well as some parts of India. Out of 10,000 to 12,000 deliveries that are conducted in the hospital annually, only around 40% of women seeking delivery are registered or booked to the hospital. The rest are unregistered, few are referred, and many present without even a single antenatal visit. The specific protocol guideline of the institute is to opt for a cesarean section for term breech delivery. Despite that, a significant number of vaginal breech deliveries are also conducted because most of these patients are unregistered due to which elective cesarean section cannot be planned on time; many arrive in advanced stages of labor; and some refuse cesarean delivery owing to financial and social issues.

Being an academic institute with comprehensive indulgence in medical education in both undergraduate and postgraduate levels, monitoring and further supervision for case-specific delivery complications are handled and sought after accordingly. Vaginal deliveries are usually conducted by OBGYN resident doctors and nursing staffs posted in labor room. For high risk cases like breech vaginal deliveries, resident doctors conduct the deliveries supervised by lecturers/senior residents. In cases of more difficult presentations, immediate assistance from consultant on call is sought.

2.2. Study Design

The study was carried out through a retrospective analysis and review of two years of case records of women who had singleton term breech vaginal delivery from April 13, 2016, to April 12, 2018. The women with live singleton pregnancy with breech presentation between 37 and 42 weeks of gestation were included in the study. The study excluded the women with preterm deliveries (<37 weeks), postterm pregnancies (>42 weeks), prediagnosed IUFD, and multifetal pregnancies. Women with postterm pregnancies in particular were excluded from the study because postterm births themselves are associated with increased perinatal morbidities. However, in our cohort, there were no women with breech presentation who delivered after 42 weeks. The process of selection of the study population is shown in Figure 1 . The available information was recorded in preformed pro forma. Ethical approval was taken from the Institutional Review Committee (IRC Code: IRC/1477/018) before conducting the study and permission was obtained from the hospital director to review the case records. The case variables studied were as follows:

•   Demographic variable: age
•   Obstetric characteristics: antenatal care (registered or unregistered), parity, gestational age, antenatal complications (GDM, hypertensive disorder, anemia, IUGR, and oligohydramnios)
•   Details of labor: total duration of labor, duration of second stage of labor, prelabor rupture of membrane, umbilical cord prolapse, need of episiotomy, perineal tear, other genital tract injuries, and birthweight
•   Postpartum complications: postpartum hemorrhage and maternal mortality
•   Perinatal complications: APGAR at 5 minutes <7, neonatal admission, and perinatal mortality

Selection of study population.

2.3. Data Analysis

The data was entered in the master chart and analysis was performed using SPSS 11.5. Descriptive statistics like frequency, percentages, and mean and standard deviation were calculated and the results were presented in tables. Association between the maternal and fetal characteristics and perinatal outcomes was estimated using Chi-square test and Fisher exact test where applicable. P < 0.05 was considered statistically significant.

2.4. Definition of the Key Terms

Term pregnancy: includes early term (37° /7 weeks to 38 6/7 weeks), full term (39° /7 weeks to 40 6/7 weeks), and late term (41° /7 weeks to 41 6/7 weeks) gestation.

•   Still birth: when signs of life are absent at birth. It includes both intrauterine and intrapartum death. Only intrapartum still birth taken into consideration for the study.
•   Early neonatal death: death of live born neonate during the first seven days of life.
•   Perinatal death: intrapartum still births plus early neonatal deaths.
•   Adverse perinatal outcomes: included low APGAR score at 5 minutes (<7), neonatal admission, and perinatal death.

There were 21,768 deliveries over the study period of two years. Total 676 breech deliveries occurred over this period, with an incidence of 3.1% of the total deliveries. Among them, 528 were term breech deliveries (between 37 and 42 weeks of gestation), accounting for 2.4% of the total deliveries. Out of 528 term breech deliveries, 434 (82.2%) women delivered through cesarean section and 94 (17.8%) of them vaginally. Ten women were excluded as they had been diagnosed with IUFD at presentation. Therefore, 84 women meeting the inclusion criteria were taken for the analysis.

For 66 (78.6%) women, vaginal breech delivery was unplanned. Thirty-six (42.9%) women presented in second stage and seven women were already in advanced stage of labor. For the remaining 23 women, even though the LSCS was planned, it could not be performed immediately, mostly because of preoccupied operation theatre. Some women, however, opted for vaginal delivery; among the 18 (21.6%) women, two had contraindications for vaginal delivery (one had oligohydramnios with IUGR; the other had IUGR) and were counseled against going for vaginal delivery. But those women did not give consent for cesarean section. They eventually had vaginal delivery with poor perinatal outcomes.

The mean age of the women in study was 25.67 ± 5.06 years and most of the women were within the age groups 20–30 years. The mean gestational age at delivery was 39 weeks with 15 (17.9%) women crossing the expected date of delivery; none of the women were beyond 42 weeks of gestation. Antenatal complications were present in 14 (16.7%) women. Among them, the most common was hypertensive disorder of pregnancy, present in seven women; four women had GDM; three had oligohydramnios; two had IUGR; and one each had anemia and antepartum hemorrhage. The demographic and obstetric characteristics of the women are presented in Table 1 .

Demographic and obstetric characteristics.

As more than two-thirds of the women visiting the center presented in the advanced stage of labor, exact duration of the labor could not be determined. For a rough estimation, however, the tentative period of the commencement of labor pain to delivery was noted. The details of labor as well as maternal complications are presented in Table 2 . There were no cases of instrumental deliveries or III- and IV-degree perineal tear. Having said that, 63.1% women required episiotomy and two women required Dührssen incision for the delivery of entrapped aftercoming head. The details of the women experiencing entrapment of aftercoming head are presented in Table 3 . There were no maternal mortalities. Among three women experiencing PPH, the etiology of two was atonic and one was traumatic.

Details of labor and maternal complications.

Details of women having entrapment of aftercoming fetal head.

The perinatal outcomes are summarized in Table 4 . Adverse perinatal outcomes (low APGAR at 5 minutes, neonatal admission, and perinatal mortality) were reported in 23.8% of deliveries. Fourteen (17.7%) neonates required admission in different wards, three with diagnosis of birth asphyxia (5 min APGAR ≤3), and others for respiratory distress. There were seven cases of perinatal mortality (five still births and two early NND) giving a mortality rate of 8.3% of the total term vaginal breech deliveries.

Perinatal outcomes of vaginal breech delivery.

The association was sought between the independent variables: maternal age, parity, booking status, period of gestation, birthweight, and perinatal outcomes against APGAR at 5 min, neonatal admission, and perinatal mortality. The results are presented in Table 5 . We also tried to find out the association between labor duration and perinatal outcomes applying logistic regression. A negative association was observed between duration of second stage of labor and perinatal outcomes (regression coefficient −0.041, P =0.178).

Association of maternal fetal characteristics with perinatal outcomes.

# Chi-square test used; ∗ Fischer exact test used.

4. Discussion

This retrospective study is aimed at determining the short-term maternal and perinatal outcomes of singleton breech vaginal delivery at a tertiary level hospital in a low resource country. The study reported very high rate of adverse perinatal outcomes (23.8%) as well as perinatal mortality (8.3%).

Large population based studies are not available to quote the incidence of breech deliveries in our setup. Hospital-based studies conducted in different tertiary level hospitals have reported the breech delivery incidence of 1.9–2.5% [ 11 , 12 ], similar to the incidence reported in our study. But this is slightly lower than the overall incidence of 3–5% [ 1 ]. The proportion of women undergoing vaginal breech delivery is minuscule because the institute has adopted the protocol of performing cesarean section for all term breech deliveries. For women who seek vaginal delivery, counseling is done regarding the hospital protocol, known contraindications, and risks associated with it. If woman gives consent after thorough briefing of all the possible complications, vaginal delivery is conducted. But almost all women opt for cesarean section after counseling. Also, because of unavailability of adequate human resources and tools for intrapartum fetal monitoring as well as lack of skills for vaginal breech deliveries, even healthcare providers prefer performing cesarean section for breech deliveries. As predicated by the study, most of the vaginal deliveries occurred because they were imminent or the operation theatre was unavailable at the moment. Nearly 80% of women are unregistered and the appropriate mode of delivery could not be planned for them beforehand. This led to many unplanned vaginal breech deliveries which in part is responsible for the high rate of adverse perinatal outcome. Nevertheless, the prevalence is not homogeneous all over the country; hospitals have reported up to 40–52% of vaginal deliveries among breech presentation with perinatal outcomes similar to or even superior to cesarean deliveries [ 12 , 13 ].

In TBT, adverse maternal outcomes which included maternal mortality or serious morbidity were noted in 3.2% women among planned vaginal delivery group. Postpartum hemorrhage was reported in 1.3% women [ 6 ]. The adverse maternal outcome we observed was postpartum hemorrhage which presented in 3.6% women. Out of three women who had PPH, two had atonic PPH and one had traumatic PPH secondary to the application of cervical incision to deliver entrapped head. Similar incidence of PPH was reported by Wasim and colleagues [ 14 ] but higher rate (13.2%) is reported in the study by Dohbit et al. [ 15 ].

Entrapment of aftercoming head is a specific intrapartum emergency associated with breech vaginal delivery and it reflects either incompletely dilated cervix or cephalopelvic disproportion [ 1 ]. This complication is more common in preterm breech deliveries and can occur in both vaginal and cesarean deliveries. Kayem et al. reported head entrapment in 13.1% among vaginal and 5.9% among cesarean deliveries of preterm breech [ 16 ]. Out of four women with this complication, two had contraindications for vaginal breech delivery; one had oligohydramnios; and for both of them IUGR was missed at the time of admission. The duo were planned for cesarean section; however, it could not be performed timely. The other two women presented in second stage of labor, one already with entrapped head. The perinatal outcome for all four deliveries was poor. All these deliveries were being monitored closely in the presence of senior residents. In two of the cases, MSV maneuver was effective in delivering head, while, for the remaining two, head could not be delivered with the maneuver alone, so help from duty consultant was sought resulting in successful delivery after the application of Dührssen's incision in the cervix.

Term babies with breech presentation are reported to have worse outcomes than cephalic ones, irrespective of the mode of delivery [ 2 ]. In our study, adverse perinatal outcomes were reported in nearly one fourth of deliveries. Azria et al. and PREMODA Study Group reported adverse perinatal outcome in 6.59% cases [ 17 ]. The criteria for adverse perinatal outcomes used were similar but we included only three variables in contrast to eight variables used by the study group. The lesser rate of morbidity in their study can be attributed to the preregistration and planning of the cases in advance and also the inclusion of only certain interventions as adverse outcomes in contrast to our methodology which has also taken into account the prospects of hospital admission as an attributable variable. Perinatal mortality or serious neonatal morbidity was reported in 5.0% of cases in vaginal delivery group in TBT [ 6 ]. Higher rate of adverse events was noted in women with age >30 years, gestation more than 40 weeks, and birthweight less than 2500 grams. Increased duration of second stage was also negatively associated with perinatal outcomes.

Our analysis reported a very high perinatal mortality among vaginal breech deliveries compared to other studies [ 11 , 12 , 15 ]. Mortalities were higher among those with gestation more than 40 weeks, or among babies weighing less than 2500 grams as compared to those with birthweight ≥2500 grams (21.05% versus 4.62%; P =0.043). Conde-Agudelo et al. on analyzing the fetal deaths also reported that risk of fetal death is minimum at 39 weeks which gradually increases with the period of gestation [ 4 ]. Some of the guidelines also recommend vaginal breech delivery only if the estimated fetal weight is between 2500 and 4000 grams to avoid growth restricted fetuses to undergo vaginal delivery [ 18 ].

Out of seven mortalities, three women who presented in LSOL and the rest in second stage of labor; none of them had prolonged labor. However, all these mortalities may not be solely associated with the mode of delivery. In two women, no other complications were identified which could have increased the chances of mortality. Two women had entrapment of aftercoming head in second stage of labor, one of which was presented to the facility with an already entrapped head in the second stage. Three women had associated obstetric complications: one had oligohydramnios with IUGR (weight 1530 grams); another had anemia and hypertensive disorder with IUGR (weight 1550 grams); and the third one had GDM. These conditions were identified at the time of delivery. Although cesarean section was planned for the first two women, failure to achieve consent resulted in vaginal breech delivery. Cases like this have been found to affect the obstetric outcomes. The treatment cost is to be borne by the patients themselves. The unmatched cost of cesarean section, hospital stay, and required medications vis-à-vis the average Nepalese income is major cause of women refusing cesarean section. Furthermore, the babies delivered from such mothers require NICU which itself is an infrastructural challenge because of limited institutes with neonatal intensive care units, the logistics associated to referral, and also the spatial difficulties with such cases. This further adds to the financial burden hitherto experienced by the patients and parties demotivating the aspiration of adopting and implementing an optimal protocol in the delivery procedure. The socioeconomic reliability of Nepalese people is generally on agriculture and animal husbandry which are highly unpredictable occupations requiring number of hours of labor time. The incidence of prolonged hospital stay as well as the need for recuperative respite for a longer duration is significantly higher in case of surgical intervention as compared to vaginal delivery which in turn delays their return to work. This deems them twice-disadvantaged: one from the hospital and recuperative cost and the other from employment struggles. Because of these financial and social issues, many women and their family members are reluctant to opt for cesarean section and prefer vaginal delivery at any cost. Though we cannot derive a conclusion solely based on this observation, these financial and social issues nevertheless play a major role in poorer maternal and perinatal outcomes as witnessed in our cases.

The higher rates of perinatal morbidity and mortality associated with vaginal breech deliveries in our study are not in compliance with results from other hospitals of Nepal [ 11 – 13 ]. This may be because of insufficient sample size in study—that those hospitals have lower numbers of total deliveries which allows them to allocate adequate human resources for the management of those cases. But well planned vaginal deliveries could also be a justification in addition to well-managed skilled resources resulting into high rate of breech vaginal deliveries in those institutions.

Following the results of this study, demonstration classes on vaginal breech deliveries have been conducted for the residents. Proper screening of the women at presentation for feasibility of vaginal delivery is assured by senior resident or consultant on duty. Also, the hospital management is requested to provide another operating room on need basis so that the women who are not suitable will not have to go for vaginal delivery because of unavailability of operating room. With these measures, we hope to experience better outcomes of vaginal breech deliveries in future.

4.1. Limitation of the Study

The current study is a retrospective analysis and has a small sample size. The population studied was heterogeneous and most of the deliveries occurred because they were inevitable rather than planned. Another limitation of the study is that we did not compare the outcomes of vaginal delivery with cesarean delivery. Because of this, we cannot make the inference from the study that the higher rate of perinatal morbidity and mortality can be attributable to vaginal mode of delivery. The study notwithstanding gave us an idea about how our current healthcare delivery for breech presentation at term is working and thus highlighted the scope for improvement.

5. Conclusion

The perinatal outcomes for vaginal breech delivery are grave with our existing health facilities and contemporary practices especially when the deliveries are not well planned. Vaginal breech delivery demands special skills, but with decreasing proportion of it, skill transfer to healthcare providers is also plummeting. This is markedly more important for low-income countries like ours where the facility for cesarean section is limited and tertiary care hospitals get overcrowded because of which patients may not get pertinent attention and intervention on time. Conclusively, larger and comprehensive studies comparing outcomes of vaginal and cesarean deliveries should follow in order to reach an incontrovertible and definitive conclusion.

Acknowledgments

The authors would like to acknowledge the nursing staff of the hospital record section in BP Koirala Institute of Health Sciences for providing with the case files of the patients included in the study. The authors are also thankful to hospital administration and Head of the department of Obstetrics and Gynecology, BPKIHS, for permitting us to conduct the study.

Abbreviations

Data Availability

Ethical approval.

The study was conducted after getting ethical approval from the Institutional Review Committee (IRC code: IRC/1477/018), and permission was obtained from the hospital director to retrieve the case records.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Breach  (English) Translated to Nepali as उल्लंघन

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